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Strategies for Minimizing Pharmaceutical Waste
in Healthcare
Pharmaceutical Waste Regulations Existing and Proposed
Jim Ostrowski Environmental Manager
Training & Outreach Program Lansing, Michigan
Office of Environmental Assistance
Housekeeping
• All lines will be muted
• Questions can be sent to us via thequestion/chat box
• We will record webinar and post online atwww.michigan.gov/deqdrugdisposal
• Notes page
Christine Grossman, Environmental Quality Specialist
Waste Programs, Lansing, Michigan 517-284-6860 or grossmanc@michigan.gov
Office of Environmental Assistance
Environmental Assistance Center (EAC)
Phone: 1-800-NO2-WASTE(1-800-662-9278)
Hours: 8:00 AM to 4:30 PM Monday – Friday
Technical Assistance Services Include:
Air Environmental Audit Privilege Waste Site Remediation Water Permit Coordination
U.S. EPA
Kristin Fitzgerald Office of Resource Conservation & Recovery
Materials Recovery & Waste Management Division Recycling & Generator Branch, Washington D.C.
703-308-8286 or fitzgerald.kristin@epa.gov
Zimmer Environmental Improvement, LLC
Catherine Zimmer Zimmer Environmental Improvement, LLC &
HEARRT Midwest, St. Paul, Minnesota 651-645-7509 or zenllc@usfamily.net
Today’s Goals
ü Environmental & Public Health Issues
ü Existing Michigan HW Pharmaceutical Rules
ü EPA Proposed Federal HW Pharmaceutical Rule
ü What To Expect
Why Cover Proposed Rule
Changes are Extensive:
• Establishes entirely newmanagement standard
• Prohibits sewering - all HWpharmaceuticals
• Proposed to require MI abandoncurrent regulations
Environmental & Public Health Issues
Pharmaceuticals An Emerging Contaminant
First detected at low levels in Europe in1970’s
Studies continue to show they are ubiquitous globally and persistent
- see http://toxics.usgs.gov &search for pharmaceuticals
Many are persistent because they are manufactured to be resistant to transformation in water
Pharmaceuticals An Emerging Contaminant
Most medications are excreted intact and end up in our WWTPs
WWTPs don’t remove drugs
Annually people continue to take more and more drugs
Above - Aerial of a Waste Water Treatment Plant (WWTP)
Left – WWTP Clarification Tank
Pharmaceuticals An Emerging Contaminant
Without change levels will continue to increase
Pharmaceuticals in environment have been shown to cause adverse impacts to amphibians, fish, and bacteria
Proposed rules memorialize EPA expects pharmaceuticals may cause adverse human health impacts
Pharmaceuticals An Emerging Contaminant
EPA’s cites that pharmaceuticals . . .
are intrinsically bioactive compounds able to impact living systems
are known to have adverse side effects that are exacerbated when combined
once released to the environment, there is little ability to prevent co-administration
See Federal Register, Volume 80 Page 58046
Pharmaceuticals Diversion - A Human Health Crisis
Pharmaceuticals are also:
• diverted and abused
• known to result inaccidental poisoning
• presently the leadingcause of accidentaldeath in the US
Above graph shows a near three fold increase in accidental deaths from prescription drug overdose from 2004 to 2014
What We Can Do Now
ü Manage inventories ü Incinerate - preferred disposal option
It destroys the chemicals and prevents them from cycling in our environment
What We Can Do Now
ü Manage only what you need
ü Prescribe least eco-toxic drugs
ü Minimize sample inventories
ü Issue sample scripts where possible
ü Issue shorter initial scripts for new prescriptions with undesirable side effects
Paradigm Switch
Reactionary Anticipatory
SHIFT
Existing Environmental Pharmaceutical Disposal Regulations
Hazardous waste regulations require each non-household site generating waste to:
ü characterize their wastes
ü determine the total weight of all hazardous generated monthly
ü determine their legal disposal options
Existing Waste Regulation
Existing Waste Regulation
Drugs are generally a …
ü Hazardous Waste (Part 111 of Act 451 in lieu of RCRA) - listed or characteristic hazardous waste
ü Liquid Industrial By-Product (Part 121 of Act 451) - not hazardous & liquid
ü Non-Hazardous Solid Waste (Part 115 of Act 451) – not hazardous & solid
Waste
Liquid
Industrial By-Product
Hazardous Waste
Solid Waste
Non-household waste subject unless excluded: Ø Hazardous if listed or characteristic Ø Liquid industrial by-product if free liquids
Waste Characterization
Hazardous Waste Generator Status:
ü Conditionally Exempt Small Quantity Generator (CESQG)
ü Small Quantity Generator (SQG)
ü Large Quantity Generator (LQG)
Existing Waste Regulation
Less
Regulation
More Regulation
Hazardous Waste Generator Status
CESQG
ü Generates < 220 lbs. non-acute HW monthly
ü Generates < 2.2 lbs. acute HW monthly
ü Never accumulates > 2200 pounds non-acute HW
ü Never accumulates > 2.2 lbs. acute HW
CESQG exempted HW must be properly disposed under other regulations:
ü Liquid industrial by-product or
ü Solid waste regulations
Need receiving facility that wants it!
Hazardous Waste Generator Status
CESQG required records include:
ü Waste characterization
ü Generator status verification
ü Special waste approval
ü Disposal records/receipts (solids)
ü Shipping records/manifests (liquids)
3 years of records must be maintained
Hazardous Waste Generator Status
Existing Waste Regulation
Estimates identify between 5% to 15% pharmaceuticals are hazardous waste (HW):
ü Listed
ü Characteristic
- Ignitable - Corrosive
- Toxic - Reactive
Ignitable D001 HW Pharmaceuticals Examples
Disinfectant hand washes
Etoposide (chemotherapy)
Faslodex (chemotherapy)
Paregoric (controlled substance)
Paclitaxel (chemotherapy)
Rubbing alcohol
Nyquil
Toxic & Acutely Toxic D004 to D043 HW Pharmaceuticals Examples
Afrin – toxic (D009)
Arsenic Trioxide – acutely toxic (P012)
Barium Hydroxide Crystals – toxic (D005)
Coumadin (Warfarin <.3%) – toxic (U248)
Coumadin (Warfarin > .3%) – acutely toxic (P001)
Epinephrine (P188)
Nicotine & salts – acutely toxic (P075)
Phentermine HCL (P046)
Corrosive D002 HW Pharmaceuticals Examples
Wart removers - trichloroacetic acid
Eye medications - acetic and phosphoric acids
Glycopyrrolate
Compounding chemicals like • Glacial Acetic Acid • Sodium Hydroxide • Carbolic acid (liquid phenols)
Reactive D003 HW Pharmaceuticals
Nitroglycerin – acutely toxic (P081) and reactive (D003) Clinatest – reactive (D003) Dry Picric Acid – reactive (D003)
Existing Regulation Universal Waste Pharmaceuticals
HW pharmaceuticals can be managed as Universal Waste (MI & FL only)
Universal Waste standards are streamlined HW standards Dual Waste – Pharmaceutical waste mixed with medical waste ü Most expensive ü Only 90 day storage ü HW and medical waste regulations
apply
Existing Regulation Universal Waste Pharmaceuticals
2004 MI established pharmaceuticals as a universal waste type
EPA reauthorized MI program August 28, 2015
Encourage all pharmaceuticals ü managed as UW (BMP) ü incinerated (BMP)
Existing Regulation Universal Waste Pharmaceuticals
Benefits: ü No counting ü No proving CESQG exempt status ü Less characterization, presume hazardous
waste ü Longer storage time ü One set of container standards ü Less training ü Less containers ü Ultimate disposal is the same, licensed HW
disposal facility
Existing Regulation Universal Waste Pharmaceuticals
Container and Labeling
ü Compatible with waste
ü Closed except to add/remove
ü Labeled “Universal Waste Pharmaceutical”
ü Date container when waste first added
Existing Regulation Universal Waste Pharmaceuticals
Storage/Accumulation ü Secured from weather, fire, physical
damage, and vandals
ü Separate incompatible materials
ü Prevent releases
ü Inspected weekly (BMP)
ü Secondary containment (BMP)
Existing Regulation Universal Waste Pharmaceuticals
Transportation & Disposal
ü Occur within one year of accumulation
ü Be in compliance with the DOT requirements
ü Accompanied by a “Shipping Document” or manifest if liquids
ü May be shipped to universal waste handler
ü Ultimate disposal is licensed HW disposal facility
Existing Regulation Universal Waste Pharmaceuticals
Shipping document must include:
ü Generator name and address of
ü Transporter name
ü Waste type and volume shipment
ü Date of generator shipment
ü Designated facility name, address, and Site ID number
Existing Regulation Universal Waste Pharmaceuticals
Shipping document or manifest must be: ü Certified by generator
ü Certified by transporter
ü Kept at least 3 years
Receiving facility must: ü verify they’re the listed designated facility
ü notify generator of receipt of shipment
Additional Resources include: • MHA Pharmaceutical
Waste Management Guide
• MHA Guide Example Posting
• Pharmaceutical Tutorial
• Universal Waste Guidance
www.michigan.gov/deqdrugdisposal
Universal Waste Pharmaceuticals
What is Federal HW Pharmaceutical Proposal?
Initial Federal Proposed Rules
2008 - EPA proposes to establish pharmaceuticals as a federal universal waste type
2013 - EPA identifies intent to develop a completely different proposal for HW pharmaceuticals due to substantial negative public comments
Current Federal Proposed Rules
September 25, 2015 - EPA issued proposed rules requiring Michigan abandon its universal waste designation and establish new healthcare/RD standards December 24, 2015 – Public comment closed
Status of Federal Proposed Rules
EPA received over 175 diverse comments from:
Reverse Distributors
States/Government Retail Pharmacists Hospitals Associations
EPA projected issuance of final rules in Fall 2016
Final rules now projected sometime in 2017
Overview
Who is impacted? 1,624 hospitals
142,400 non-hospital healthcare facilities
28 reverse distributors
Purpose
Protect water resources
Provide regulatory relief to healthcare and pharmacies
Authorize reverse distribution practices
Eliminate DEA controlled substance overlap
Formalize adhoc interpretations
EPA Recommendations
Manage all pharmaceuticals, both HW and non-HW pharmaceutical under proposal
Exempted CESQGs opt-in
Incineration of pharmaceuticals at licensed hazardous waste incinerator unless otherwise prohibited under the land disposal restrictions
Above – Aerial Photo of a Hazardous Waste Incinerator
EPA Primary Goal
Protect water resources by sending most unwanted post manufacture
pharmaceuticals for disposals via incineration
Key General Benefits
Divert 6,400 tons of hazardous waste (HW) pharmaceuticals from potentially
reaching our water resources to incineration
Novel Provisions
Establishes completely new regulatory scheme nationally for HW pharmaceuticals
ü 40 CFR Part 266, Subpart P for HW Pharmaceuticals
ü Mandatory for SQGs/LQGS
ü Optional for CESQGs
Novel Provisions
Prohibits wasting HW pharmaceutical to sewer
Mandates Michigan abandon pharmaceuticals as a universal waste
Novel Provisions
Concludes that pharmaceutical sent for reverse distribution are waste
Authorizes HW pharmaceutical storage at RD without HW storage license, financial assurance, or corrective action
Key General Provisions
Establishes separate management requirements for
• Potentially Creditable HW Pharmaceuticals” in RD
• “Non-Creditable HW Pharmaceuticals” being disposed by Healthcare
• Evaluated HW Pharmaceuticals being disposed by RD
Key Reverse Distributor Benefits
Assigns value to RD pharmaceuticals for
ü manufacture assigned credit ü street value for non-controlled
pharmaceuticals
Authorizes HW pharmaceutical storage at RD without HW storage license, financial assurance, or corrective action obligation
Healthcare Defined
Healthcare is specifically defined as any person that
• provides preventative, diagnostic, therapeutic, rehabilitative, maintenance or palliative care, and counseling, service, assessment or procedure with respect to the physical or mental condition, or functional status, of a human or animal or that affects the structure or function of the human or animal body
• sells or dispenses over-the-counter or prescription pharmaceuticals.
Healthcare Defined
Healthcare includes:
• Independent dental, veterinary, and medical offices • Hospitals, medical and veterinary • Health clinics • Surgical clinics • Chemotherapy clinics • Coroners offices – NEW • Adult care facilities – NEW
Healthcare Defined
Healthcare is defined to include all pharmacies, including:
• Retail brick and mortar pharmacies
• Mail order pharmacies • Compounding pharmacies • Long term care pharmacies
Reverse Distributor (RD) Defined
Any person that receives and accumulates potentially creditable
hazardous waste pharmaceuticals for the purpose of facilitating or verifying
manufacturer’s credit
Pharmaceutical Defined
Generally includes any chemical formulation intended to:
• diagnosis, cure, mitigate, care for, treat, or prevent disease or injury or
• formulated to effect the structure or function of the body of a human or other animal
Pharmaceutical Defined
Pharmaceuticals includes:
• Prescription & OTC drugs • Dietary supplements • DEA controlled substances unless
managed to meet exemption • Contaminated PPE – NEW • Pharmaceutical spill clean-up NEW
Pharmaceutical Defined
Pharmaceuticals do not include:
• Medical waste • R & D pharmaceuticals • Pharmaceutical manufacture waste • Exempt DEA pharmaceuticals – NEW • Exempt “empty” containers and
syringes – NEW
Rule of Thumb: Includes any formulation with a Drug Fact label
Hazardous Waste Pharmaceutical Defined
Listed Pharmaceutical Characteristic Pharmaceutical
Empty
Current federal rules
• Container residues are acute P-listed HW, unless triple-rinsed or cleaned by an equivalent method
• Long standing EPA policy that vials, dixie cups, soufflé cups, blister packs are not empty once dose is administered
Clarify Empty
Proposed federal rules:
Unit-dose containers (packets, cups, blister packs) and dispensing bottles (vials up to 1 liter or 1000 pills) are empty and exempt if:
ü All content is fully dispensed (rendering the container “RCRA empty”) AND
ü Container is destroyed to prevent diversion (e.g., crushed) - NEW
Clarify Empty
Proposed federal rules
Dispensed syringes are RCRA empty and exempt if:
ü The syringe has been used to administer the pharmaceutical to a patient, AND
ü The syringe is placed in a sharps containers that is managed appropriately
Clarify Empty
All other containers, including delivery devices, that once held listed P or U or exhibit a characteristic, must be managed as hazardous waste, including: ü IV bags and tubing ü Nebulizers ü Ointment tubes
Eliminate DEA Overlap
Examples of current dually regulated pharmaceuticals by EPA and DEA include:
• Chloral hydrate (U034) • Fentanyl sublingual spray (D001) • Phenobarbital (D001) • Valium injectable (D001) • Testosterone gels (D001)
Eliminate DEA Overlap
Current - Meet both DEA and HW
Proposed – Exempt controlled if managed to meet DEA regulations and incinerate at:
ü a licensed municipal solid waste incinerator or
ü a licensed hazardous waste incinerator
Above: Municipal solid waste incinerator
Clarifies HW Status of Specific Pharmaceuticals
Epinephrine salts are not P-listed wastes
Phentermine salts are not P-listed wastes
Federal register sought comment on HW status of nicotine patches, gum, lozenges as acutely hazardous
Potentially Creditable HW Pharmaceutical Defined
Includes HW pharmaceuticals that have the potential to receive manufacturer credit
Must: • Be unused/un-administered • <1 year of expiration • In original packaging
Potentially Creditable HW Pharmaceutical Defined
Does not include: • Samples • > 1 year expired • Removed from their original container • Re-packaged for dispensing • Generated during patient care • Refused by a patient
Potentially Creditable HW Pharmaceutical Defined
Potentially creditable HW pharmaceuticals do not include:
• Evaluated hazardous waste pharmaceuticals
• Non-empty container residues • Contaminated PPE • Spill clean-up
Potentially Creditable HW Pharmaceutical Defined
If there is no reasonable expectation of credit, the HW pharmaceutical cannot go to an RD
If an RD receives non-creditable HW pharmaceuticals, it must:
• Prepare an “unauthorized waste report” and send it to the Healthcare facility and to EPA
• Manage the waste appropriately
Non-Creditable HW Pharmaceutical
Non-creditable HW pharmaceuticals includes HW pharmaceuticals that are not
eligible for manufacturers credit
Evaluated HW Pharmaceutical
A hazardous waste pharmaceutical that was potentially creditable but has been
evaluated by a RD to establish manufacturer credit eligibility and will not be sent to another pharmaceutical reverse
distributor for further evaluation
Healthcare General Requirements
One-time notification as Healthcare Facility
Performance-based training for healthcare workers
CESQGs can opt in with notification
Healthcare Accumulation Potentially Creditable Pharmaceuticals
No specific labeling
No specific accumulation requirements
No specific time limits
Healthcare Shipping Potentially Creditable Pharmaceuticals
• Written, advance notice of shipments to RD
• Confirmation of receipt of shipment by RD
• Recordkeeping of shipments/confirmation to/from RD
• Allows common carrier
• HW codes not required for shipment
Healthcare Accumulation Non-Creditable Pharmaceuticals
• Closed containers secured to prevent access
• Label as “Hazardous Waste Pharmaceuticals”
• One year accumulation limit
• Segregate wastes that can’t be incinerated per land disposal restrictions (e.g., arsenic trioxide)
• HW codes not required on accumulation containers
Healthcare Shipping Non-Creditable HW Pharmaceuticals
• HW transporter required
• Manifesting required
• Must meet U.S. DOT requirements
• HW codes not required on manifest
• “Hazardous waste pharmaceuticals” must be noted in Box 14 of manifest
• Land disposal notice not required but TSD must know codes to treat to LDRs
Key Healthcare Benefits
Extends 90/180 day accumulation to 1 year
Eliminates pharmaceutical waste counting
Eliminates satellite/accumulation area requirements
Reduces training and documentation requirements
Eliminates LQG biennial reporting
Clarifies ambiguous and overlapping requirements
Healthcare CESQG Allowances
A CESQG healthcare facility may….
• send potentially creditable hazardous waste pharmaceuticals to a pharmaceuticals reverse distributor
• send potentially creditable and non-creditable hazardous waste pharmaceuticals to their owner or a site contracted to supply their pharmaceuticals for disposal under subpart P by receiving facility
Healthcare Facilities Receiving CESQG HW Pharmaceuticals
Receiving healthcare facility must:
• own or supply via contract pharmaceuticals to CESQG
• operate under Subpart P
• manages non-creditable pharmaceuticals from the CESQG under subpart P
• keep records of the creditable and non-creditable pharmaceuticals received from off-site for 3 years
LTC Allowance
Long-term care CESQGs can dispose their non-creditable hazardous waste
pharmaceuticals in a DEA registered collection receptacle managed to meet the
DEA controlled substance regulations
Reverse Distributor General Requirements
• Only authorized to accept potentially creditable HW pharmaceuticals
• Must have contingency plan
• Must documented staff training
Reverse Distributor (RD) General Requirements
• One-time notification as RD
• Maximum of 3 RDs before disposal
• Notification if receive shipment of non-creditable HW pharmaceuticals
• Biennial reporting
Reverse Distributor Accumulation Potentially Creditable HW Pharmaceuticals
No specific labeling or container standards
Each Reverse Distributor:
• Must evaluate whether “creditable” under manufacture contract within 21 days or receipt
• Is allowed maximum of 90 day storage
Reverse Distributor Accumulation Potentially Creditable HW Pharmaceuticals
Within 90 days of receipt the RD must:
ü Assign credit to healthcare facility AND send to a licensed HW TSDF for treatment or disposal in accordance with “Evaluated HW Pharmaceutical” requirements OR
ü Send to another RD to evaluate credit
Reverse Distributor Accumulation Potentially Creditable HW Pharmaceutical
Each Reverse Distributor must have:
• Inventory of HW pharmaceuticals
• Facility security
Reverse Distributor Maximum Transfers Allowed
Maximum additional storage duration is 270 days until TSD disposal is required
Reverse Distributor Accumulation Evaluated HW Pharmaceutical
• Must designate an on-site accumulation area
• Must conduct and keep a log of weekly inspections
• LQG training for personnel handling evaluated HW pharmaceuticals
Reverse Distributor Accumulation Evaluated HW Pharmaceuticals
• Closed containers for liquids or gels
• Wastes that can’t be incinerated must be accumulated separately (e.g., arsenic trioxide P012)
• HW codes required prior to transport off-site
• Label as “Hazardous Waste Pharmaceuticals”
Reverse Distributor Shipping Potentially Creditable HW Pharmaceuticals
• Written, advance notice of shipments to next RD
• Confirmation of receipt of shipment from receiving RD
• Recordkeeping of shipments to RD
• Common carrier allowed
• HW codes not required during shipment
Reverse Distributor Shipping Evaluated HW Pharmaceuticals
• HW transporter required
• Manifesting required
• Must meet U.S. DOT requirements
• HW codes not required on manifest
• “Hazardous waste pharmaceuticals” must be noted in Box 14 of manifest
• Land disposal notice not required but TSD must know and treat to LDRs
Key Changes for Michigan
Proposal eliminates current universal waste handlers locations that accumulate larger shipment volumes for HW incineration Secondary locations accepting non-creditable pharmaceuticals must be: • transfer facility (10 day storage) or • License hazardous waste TSD
Wrap Up
Federal HW Pharmaceutical Rule proposes to: • Establish new regulatory framework for HW
Pharmaceuticals under 40 CFR, Part 266, Subpart P
• Prohibit sewering of HW Pharmaceuticals from all of healthcare and reverse distribution, including CESQGs!
Wrap Up
Federal HW Pharmaceutical Rule proposes to:
• Authorize reverse distribution HW pharmaceuticals storage without a license by establishing:
• Potential Creditable HW Pharmaceuticals
• Non-Creditable HW Pharmaceuticals
• Evaluated HW Pharmaceuticals
• Would require Michigan & Florida to abandon their universal waste designation for national consistency
Wrap Up
Provides mandatory management standards HW pharmaceuticals from SQG and LQGs
Encourages CESQGs “opt in” to standards
Encourages management of all pharmaceuticals under new standards
Federal Proposed Rules Effective Date
When final rulemaking is issued it becomes effective:
• Immediately in all states and territories for sewer ban
• Upon state adoption for all other provisions
• Final rules may be different than proposed rules
Glimpse of What to Expect
Sites relying on Michigan’s universal waste rule can continue to do so until:
ü the federal rules final
ü Michigan promulgates rules to adopt the final rules into the state program under Part 111
Bottom Line
Managing all pharmaceuticals as a universal waste in Michigan, regardless of generator status, will establish procedures that make
compliance with the new subpart for healthcare easy!
Bottom Line
To establish a pharmaceutical waste program or refine an existing program:
• See MHA Guide Universal Waste Guide Sheet • See Pharmaceutical Waste Disposal Vendor
List • Consider 10 Step Process • Call with questions!!!
Questions?
Thank you for your continued commitment to protecting our shared resources!
Questions?
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